Covered Services

Routine Physicals

Routine physical exams are covered according to the following schedule:

For children:

  • Six visits per year (0–12 months)
  • Three visits per year (12–24 months)
  • One visit per year (2–18 years)

For adults:

One physical exam is covered each calendar year.

Waiver of Copayment 

In-network routine physicals are covered 100% with no copayment.

Out-of-network preventive care is covered 70% after the deductible.

Applied Behavior Analysis

Applied Behavior Analysis (ABA) benefits for children with autism syndrome are expanded to cover dependent children over the age of seven.  ABA is covered for dependent children from their third birthday if they have been diagnosed with an Autism Spectrum Disorder. Visits are covered with $30 copayment for in-network services or 70% after deductible for out-of-network services.

Emergency Coverage

The BCBS PPO provides benefits for emergency medical services whether you are in or outside of Massachusetts. These emergency medical services may include inpatient or outpatient services by providers qualified to furnish emergency medical care and that are needed to evaluate or stabilize your emergency medical condition.

In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). You pay a $100 copayment for in-network or out-of-network emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. The out-of-network deductible does not apply.

Within the Enrollment Area

You will receive full coverage after a $100 copayment per person per visit for hospital emergency room treatment you receive at a hospital in the plan network. This copayment will be waived, however, if you are immediately admitted to the hospital.

Outside the Enrollment Area

When you are temporarily outside the enrollment area, the BCBS PPO will cover emergency room treatment in full after a $100 copayment if the illness or injury is sudden and life-threatening. Emergency treatment received at a physician’s office outside the enrollment area will be covered in full after a $30 copayment per person per visit.

Home Health Care Benefits

The BCBS PPO pays benefits for medically necessary home care services and supplies, such as intermittent skilled nursing care and physical therapy, at 100% when you use a participating provider, and at 80% (after the deductible when you use an out-of-network provider).

Coverage is also provided for the following services when determined to be a medically necessary component of the intermittent skilled nursing care or physical therapy:

  • Occupational therapy
  • Speech therapy
  • Medical social work
  • Nutritional consultation
  • Home health aide
  • Durable medical equipment

Prescription Drug Benefits

As a member of the Boston University Health Plan, you will automatically be enrolled in the OptumRx Prescription Drug Coverage. Learn more about your prescription drug coverage.

Mental Health and Substance Abuse Benefits

The BCBS PPO will pay benefits for inpatient and outpatient treatment of mental health and substance abuse.

Mental Health and Substance Abuse Benefits
Mental Health BCBS PPO Network Out-of-Network
Inpatient admissions to a licensed general hospital Covered in full Covered at 70% after deductible
Inpatient admissions to a mental health facility Covered in full Covered at 70% after deductible
Outpatient services $30 copayment per visit Covered at 70% after deductible
Substance Abuse
Inpatient admissions Covered in full Covered at 70% after deductible
Outpatient services $30 copayment per
Covered at 70% after deductible
Detoxification for drug/alcoholism Covered in full Covered at 70% after deductible